M. K. Allami, FRCS(Trauma and. Orth), Specialist Orthopaedic. Registrar. Leeds Teaching Hospitals NHS. Trust, Beckett Street, Leeds, LS9. 7TF, UK. D. Fender, FRCS (Trauma and. Orth), Consultant Orthopaedic. Surgeon. Freeman Hospital, Freeman Road,. H
HIP. REPLACEMENT. REVIEW. OF 92 PATIENTS. AT. 15 TO. 20 YEARS. LARS. NEUMANN, ... clinical results and radiologicalloosening on the Harris scale.
OHS, the EQ-5D and the SF-12 are short questionnaires with 12, five ..... scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project:.
Background: In total hip arthroplasty, techniques for cementing the femoral ... twenty years, five (5%) had a revision because of aseptic loosening of the femoral ...
... to the introduction of the long posterior-wall cup and the femoral stem was later ... with a 29 mm head (Biomet, Bridgend, UK) or a Charnley prosthesis with a ...
biocompatible is the titanium alloy extra low interstitial (ELI)2 Tiâ6Alâ4V; its composi- tion is 90 wt% Ti, 6 wt% Al, and 4 wt% V. The optimal properties for this material are produced by hot forging; any subsequent deformation and/or heat treat
We performed Charnley total hip arthroplasties on 64 patients (71 hips) between 1976 and 1984 for moderate congenital acetabular dysplasia in which a ...
575. INTRODUCTION. Total hip replacement (THR) provides a very effective ... arthroplasty, bilateral arthroplasty; those transferred or initially treated at other ...
Developmental dysplasia of the hip (DDH) is a major risk factor for secondary hip osteoarthritis.1. The prevalence of DDH varies among different ethnic.
most deprived underwent surgery at an earlier age (p = 0.04), had more ... dislocation (odds ratio 5.3, p < 0.001) and mortality at 90 days (odds ratio 3.2, p = 0.02). Outcome, risk of dislocation and early mortality after a total hip replacement are
Talal Ibrahim, Mayyar Ghazal Aswad, Joseph J Dias, Andrew R Brown, Colin N ... Address correspondence and reprint requests to: Dr Talal Ibrahim, Division of ...
Keywords: Total HIP replacement, hemiarthroplasty, fracture neck of femur. 1. ... difference in the histology of the cartilage when compared to a group of control ...
THE JOURNAL OF BONE AND JOINT SURGERY hemiarthroplasty or revision hip arthroplasty were excluded. A total of 99 patients presented with 101 first-.
pain associated with hip joint pathology, while maintaining the mobility and stability of .... Quadriceps and knee bending ..... ProtrusioAcetabulumWith Amp Insitu.
and the types of arthroplasty performed are shown in Tables. II and ... arthroplasties performed. Number of ..... in all 12 a Girdlestone arthroplasty was performed.
Gonzalez Della Valle A, Serota A, Go G, Sorriaux G, Sculco TP, Sharrock NE, et al. Venous thromboembolism .... Yu HT, Dylan ML, Lin J, Dubois RW. Hospitals' ...
Abstract: Instability after total hip arthroplasty (THA) is not a rare occurrence. Numerous factors have been associated with dislocation including surgical approach, implant design, failure to restore proper hip mechanics and soft tissue restraints,
V early osteointegration. On-growth of bone to porous coated prostheses is ... rich femoral component or with the ce- ... total hip arthroplasty in dogs (1, 2). Loo-.
Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem ... following total joint replacement.12 A retrospec- tive study by ...
Total hip replacement (THR) is a very common procedure undertaken in up to 285 000 .... diagnosis can include activity-related pain, aseptic loosening,.
an ideal total hip replacement with a large femoral head and a high head-neck ratio. B: Cam-type impingement in the native hip caused by a reduced femoral head-neck offset and similar impingement in a prosthetic hip with a small femoral head and a sk
THE JOURNAL OF BONE AND JOINT SURGERY. Variables determining outcome in total hip replacement surgery. O. Rolfson,. L. E. Dahlberg,. J-Ã . Nilsson,.
90% (Schulte et al 1993; Neumann, Freund and SÃËrenson. 1994). Since its ..... Fowler JL, Gie GA, Lee AJC, Ling RSM. .... Clin On/top l993;292: 191-201. VOL.
the Orthopedic and Traumatologic Research Fund. No benefits in any form have been received or will be received from a commercial party related directly or ...
Outcome of Charnley total hip replacement across a single health region in England THE RESULTS AT FIVE YEARS FROM A REGIONAL HIP REGISTER David Fender, W. M. Harper, Paul J. Gregg From the Universities of Leicester and Newcastle upon Tyne, England
sing a regional arthroplasty register we assessed the outcome at five years of 1198 primary Charnley total hip replacements (THRs) carried out in 1152 patients across a single UK health region in 1990. Information regarding outcome was available for 1080 hips (90%) and 499 had an independent clinical and radiological assessment. By five years the known rate of aseptic loosening was 2.3%, of deep infection 1.4%, of dislocation 5.0% and of revision 3.2%. The radiological assessment of 499 THRs revealed gross failure in a further 5.2%, which had been previously unrecognised. The combined rate of failure of nearly 9% is higher than those published from specialist centres and surgeons, but is probably more representative of the norm. Our study supports the need for a national register and surveillance of THRs. It emphasises that all implants should be followed, and suggests that the results of such surgery, when performed in the general setting, may not be as good as expected.
J Bone Joint Surg [Br] 1999;81-B:577-81. Received 28 January 1999; Accepted after revision 18 February 1999
The Charnley total hip replacement (THR) has a long and established record and is regarded as one of the 6,7 optimum implants. There are many reports of the longterm follow-up and outcome of the Charnley prosthesis which show a survival at ten years of more than 90% in patients over 60 years of age, but most of these are from single centres or surgeons, often with a specialist interest in 7-14 hip surgery. The relevance of these studies to the average orthopaedic surgeon in a non-specialist hospital is not known. The published data from the Norwegian and Swedish national arthroplasty registers include many hospitals and surgeons, but revision is the only outcome measure used, and this may be unreliable because of differing indications for revision. The broad scale of such registers also means that data may be missing or incomplete. Our prospective, observational study has relevance for a number of these issues. Utilising a regional register, we assessed a large cohort of consecutive primary Charnley THRs independently at five years, to give an accurate outcome of the early results of this prosthesis when performed in a wide and varied setting by different surgeons.
We studied all patients who had had a primary Charnley THR during 1990, as registered with the Trent Regional Arthroplasty study (TRAS). This is the only regional arthroplasty register in England. Since the beginning of 1990 it has recorded all primary total hip and knee replacements performed throughout the Trent region. Patients are entered on the register by the surgeon carrying out the operation who completes a standard form at the time of the procedure and returns it to the study centre. The form contains clinical, medical and operative details which are then entered into a computerised database. The data are validated by a peripatetic clerk, who checks theatre records, consultant records and the patient administration system of each hospital to ensure that no information is lost and that the data provided are accurate. In 1995 we began a detailed five-year assessment. An attempt was made to contact all living patients, inviting them to attend their local hospital for a clinical and radiological assessment. This was performed by a single independent observer (DF), using the standard system for 577
DAVID FENDER, W. M. HARPER, PAUL J. GREGG
Fig. 1 Algorithm showing the breakdown of the cohort and the outcome data available.
recording results as proposed in the consensus document by the Société International de Chirurgie Orthopédique et de Traumatologie, the Task Force on Outcome Studies of the American Academy of Orthopaedic Surgeons, and the Hip 15 16 which has subsequently been validated. Society, Patients unable to attend were given the option of an assessment by telephone and were sent a simple questionnaire regarding their hip replacement. Patients who did not respond were written to again and then traced by the Office of National Statistics (ONS). In addition, an attempt was made to review all orthopaedic entries in the medical notes of the cohort, and basic details regarding the THR were sought from their general practitioner. In order to compare the group of patients who were clinically and radiologically assessed with those who were not, data were analysed by logistic regression models using SPSS version 7.5 for Windows (SPSS Inc, Chicago, Illinois). During 1990, 1198 Charnley THRs were performed on 1152 patients under the care of 56 consultants in 18 NHS and six private hospitals. There were 703 women and 449 men with a mean age at operation of 69.1 years (21 to 103); 19% were less than 60 years of age. The preoperative diagnosis was osteoarthritis (OA) in 87%, rheumatoid arthritis (RA) in 7% and miscellaneous in the remaining 6%. In 82% of the procedures a clean-air theatre was used, in 11% a standard general theatre and in the remaining 7% no information was available about the theatre. All patients received prophylactic antibiotics. The procedure was performed by a consultant in 49% of cases, a senior orthopaedic trainee assisted by a consultant in 10%, a senior orthopaedic trainee without a consultant in 34% and by other grades of surgeon in 7%.
Results Response rates and patient assessment (Fig. 1). We were able to review the medical notes of 1158 of the 1198 THRs.
Forty sets were not located. Of the notes scrutinised, 1130 contained detailed information on the operation which was analysed to determine intraoperative complications. Such information was missing from the remaining 28 sets. At five years, 226 (20%) patients with 231 THRs had died. A review of the medical notes for this group provided data on the outcome for 221 hips. Of the remaining 967 arthroplasties, 731 (76%) had some form of independent review. A clinical and radiological assessment was performed on 499 (52%) and a telephone or simple self-administered questionnaire on 230 (24%). Information for five years of follow-up was also available from the medical notes or the records of the general practitioner for a further 130 THRs in patients known to be alive, but were missing for 108 hips. Outcome data at five years were available for 1080 THRs (90%). Data from this verified and validated group are analysed below together with information from those which had been independently assessed. Complications during operation. Complications occurred during the operation in 49 of 1130 procedures (4.4%) (Table I). Fracture or perforation of the femur led to one case of long-term palsy of the sciatic nerve associated with extrusion of cement, migration of one stem towards the knee and stem revision for aseptic loosening. Acetabular fractures or perforations were associated with two revisions, one for aseptic loosening and one for an infection, and two dislocations. One patient died from malignant hyperpyrexia and another, who developed disseminated intravascular coagulopathy, collapsed with a pulmonary Table I. Number (%) of intraoperative complications in 1130 operations Complication Fracture/perforation of the femur Systemic Fracture/perforation of the acetabulum Instrument/cement problems Instability
20 11 8 7 3
(1.8) (1.0) (0.7) (0.6) (0.3)
THE JOURNAL OF BONE AND JOINT SURGERY
OUTCOME OF CHARNLEY TOTAL HIP REPLACEMENT ACROSS A SINGLE HEALTH REGION IN ENGLAND
Table II. Number (%) of postoperative complications in 1080 operations Complication
Urinary retention/infection Dislocation Pulmonary embolism Wound infection/haematoma Deep-venous thrombosis Systemic in postoperative period Known loosening Deep infection Upper gastrointestinal haemorrhage Trochanteric bursitis/nonunion Recurrent subluxation Sciatic nerve palsy
embolus but was successfully resuscitated. Two of the prostheses which were found to be unstable at operation, had recurrent dislocations, one of which needed exploration and augmentation of the acetabular component. Postoperative complications. By five years, 305 of 1080 THRs (28.2%) had encountered some form of complication, some of them multiple (Table II). Many of these were related to the urinary tract (6.2%), thromboembolic disease (5.7%), superficial wound infection or haematoma (3.1%) or to medical problems in the immediate postoperative period (2.6%). Specific complications relating to the prosthesis included dislocation in 54 (5%), of which ten (0.9%) had more than one episode. Loosening occurred in 25 (2.3%) and a proven deep infection in 15 (1.4%). All of the latter operations had been performed in a clean-air theatre and antibiotic prophylaxis had been used. Revisions. By five years, 35 of 1080 prostheses (3.2%) had undergone revision. Both components had been revised in 22, the acetabulum alone in three and the femoral component alone in ten. The indications for revision were aseptic loosening in 40%, infection in 37% and recurrent dislocation in 23%. Clinical and radiological assessment. A standard clinical and radiological examination has been carried out on 499 patients and a further 231 have been assessed by telephone or by a simple questionnaire. The standard assessment 17 included the calculation of a Harris hip score (HHS). The mean HHS was 79.4 and when graded as described by Harris, 51% had a good or excellent outcome (Fig. 2). Patient satisfaction was 94.1% (530 of 563; direct questioning in the clinic 470 of 499; and by telephone 60 of 64). Radiographs were obtained and assessed for the 499 THRs reviewed in the clinic. It was already known that 19 had failed since 14 had been revised and five were awaiting operation for loosening. Assessment of the remaining 480 revealed a further 25 (5.2%) previously unrecognised radio-
Fig. 2 The Harris Hip Score in 499 patients.
logical ‘failures’ with gross migration, fracture of the cement or extensive lucencies. The overall number of failures in this group was therefore 44 of 499 (8.8%). In order to assess whether this unrecognised radiological failure was applicable to the whole cohort, using multivariate logistic regression analysis we compared the radiographs of 480 THRs not known to have failed with the remaining 448 THRs which did not have radiographs and were not known to have failed. There was no significant difference for the age of the patient (p = 0.82) or the primary diagnosis (p = 0.24) but there was for gender (p = 0.006): more male patients were radiologically assessed (41%) than were not (32%) (Table III). A further comparison of the group of previously unrecognised radiological ‘failures’ with those which had satisfactory radiographs at five years showed no significant difference for age (p = 0.53), gender (p = 0.25) or primary diagnosis (p = 0.39), using multivariate logistic regression analysis (Table IV). There is a possible potential for bias, with concerned patients or those not under regular review more likely to accept the invitation for a clinical assessment. This may explain the higher proportion of men attending for radiological assessment with an increased likelihood of them having radiological signs of failure. This did not reach statistical significance.
Discussion This is the first study in the United Kingdom to assess independently the outcome of the primary Charnley THR across a health region. It gives a unique insight into the objective and subjective outcomes of this commonly used prosthesis.
Table III. Comparison of groups which did and did not have a radiological assessment Age (%)
VOL. 81-B, NO. 4, JULY 1999
Primary diagnosis (%)
Yes (n = 480) No (n = 418)
DAVID FENDER, W. M. HARPER, PAUL J. GREGG
Table IV. Comparison of the satisfactory and unsatisfactory radiological assessments Age (%)
Primary diagnosis (%)
Radiological ‘failure’ % male ≤60
Yes (n = 25) No (n = 455)
Table V. Summary of a selection of published results of the Charnley prosthesis Author (year)
Source of data 8
Brady and McCutchen 9
Number Follow-up (yr)
Revision rate (%)
10 to 12 (70.5%)
5 to 15
Garellick et al
12 to 16 (100%)
9.5 to 11 (67%)
2.9 (95% CI 2.3 to 3.4)
<5.0 (all revisions)
Salvati et al
Schulte et al
Marston et al
Espehaug et al
Malchau et al
5% cup 7% stem
Since the initial description by Charnley there have been many series published (Table V). Specialist centres and surgeons have reported rates of failure of less than 10% 7-14 and a recent randomised, proat more than ten years spective trial from a single centre with differing grades of 19 surgeon, reported a revision rate of 4% at 6.5 years. Evidence from the Scandinavian registers indicate five-year 20 revision rates of 2.9% in Norway and less than 5% in 21 Sweden. Our known loosening rate of 2.3% and revision rate of 3.2% compare favourably with these results. When the unrecognised radiological failures are included, however, the estimated combined failure rate is nearly 9%. 22 Britton et al reported similar results, with revision or severe pain in 5.6 ± 3.4% at six years for 159 Charnley THRs performed by a single surgeon from a non-specialist 22 unit. Our results and those of Britton et al are worse than those from the specialist centres which often use revision as the definition of failure (Table V), but are probably of more relevance for clinicians, patients and managers of healthcare in the UK. The rate of deep infection of 1.4% is similar to the 0% to 9,19,23 The dislocation rate 1.4% reported in recent studies. of 4.6% is higher than the 2% to 4% reported from smaller 12,19,23 series. These are an accurate indication of expected rates within the NHS and provide a benchmark for comparison, but whether they are acceptable or could be improved upon is open to debate. The overall patient satisfaction of
92% survival at ten years
3.0 5/54 stem
18 to 26 (193/1324)
Patients Other comments satisfaction (%)
85% pain free
13% to 14% estimated from survival curve at 16 years 4 loose on 4.0 radiograph
94.1% is high and similar to that of other published 9,11 series. National arthroplasty registers are well established in Norway and Sweden and have a proven record of providing quality assurance of the practice of joint replace20, 21, 24 ment. Our study, utilising the TRAS, is a unique observation of THR in the UK and highlights the potential of such a register to assess the outcome of major joint arthroplasty. Most of the patients with unrecognised radiological failures had been discharged from routine clinical follow-up, and a register based solely on revisions would have given a falsely optimistic impression of the performance of the implant. This confirms and emphasises the need 3-5 for long-term follow-up, particularly by radiographs. If the recent problems with the Capital THR (3M Healthcare) are not to be repeated, some form of registration and surveillance of implants should be instituted. The need for this for all implants is further emphasised by the findings which indicate that the results using a prothesis of proven reliability, performed in a general setting and independently assessed, may not be as good as expected. We thank the orthopaedic surgeons throughout the Trent Region who have supported the Trent Regional Arthroplasty Study and the Office of National Statistics for the tracing study. The Department of Health funded the five-year review of the 1990 cohort of primary THRs performed in Trent. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. THE JOURNAL OF BONE AND JOINT SURGERY
OUTCOME OF CHARNLEY TOTAL HIP REPLACEMENT ACROSS A SINGLE HEALTH REGION IN ENGLAND
References 1. Medical Device Agency. Hazard notice. London: MDA, 1998 (MDA 9801). 2. Muirhead-Allwood SK. Lessons of a hip failure. BMJ 1998;316: 644. 3. Sochart DH, Long AJ, Porter ML. Joint responsibility: the need for a national arthroplasty register. BMJ 1996;313:66-7. 4. Murray DW, Carr AJ, Bulstrode CJ. Which primary total hip replacement? J Bone Joint Surg [Br] 1995;77-B:520-7. 5. Bulstrode CJK, Murray DW, Carr AJ, Pynsent PB, Carter SR. Designer hips: don’t let your patient become a fashion victim. BMJ 1993;306:732-3. 6. Bulstrode CJ. Keeping up with orthopaedic epidemics. Br Med J 1987;295:514. 7. Wroblewski BM, Siney PD. Charnley low-friction arthroplasty of the hip: long term results. Clin Orthop 1993;292:191-201. 8. Brady LP, McCutchen JW. A ten-year follow-up study of 170 Charnley total hip arthroplasties. Clin Orthop 1986;211:51-4. 9. Older J. Low-friction arthroplasty of the hip: a 10-12 year follow-up study. Clin Orthop 1986;211:36-42. 10. Eftekhar NS. Long-term results of cemented total hip arthroplasty. Clin Orthop 1987;225:207-17. 11. Garellick G, Herberts P, Str¨omberg C, Malchau H. Long-term results of Charnley arthroplasty: a 12-16 year follow-up study. J Arthroplasty 1994;9:333-40. 12. Salvati EA, Wilson PD Jr, Jolley MN, et al. A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements. J Bone Joint Surg [Am] 1981;63-A:753-67. 13. Schulte KR, Callaghan JJ, Kelley SS, Johnston RC. The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up: the results of one surgeon. J Bone Joint Surg [Am] 1993;75-A:961-75. 14. Wroblewski BM. 15-21 year results of the Charnley low friction arthroplasty. Clin Orthop 1986;211:30-5.
VOL. 81-B, NO. 4, JULY 1999
15. Johnston RC, Fitzgerald RH Jr, Harris WH, et al. Clinical and radiographic evaluation of total hip replacement: a standard system of terminology for reporting results. J Bone Joint Surg [Am] 1990;72-A: 161-8. 16. Katz JN, Phillips CB, Poss R, et al. The validity and reliability of a total hip arthroplasty outcome evaluation questionnaire. J Bone Joint Surg [Am] 1995;77-A:1528-34. 17. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fracture: treatment by mold arthroplasty. J Bone Joint Surg [Am] 1969;51-A:737-55. 18. Charnley J. Arthroplasty of the hip: a new operation. Lancet 1961;i: 1129-32. 19. Marston RA, Cobb AG, Bentley G. Stanmore compared with Charnley total hip replacement: a prospective study of 413 arthroplasties. J Bone Joint Surg [Br] 1996;78-B:178-84. 20. Espehaug B, Havelin LI, Engesaeter LB, Vollset SE, Langeland N. Early revision among 12 179 hip prostheses: a comparison of 10 different brands reported to the Norwegian Arthroplasty Register, 1987-1993. Acta Orthop Scand 1995;66:487-93. 21. Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden: follow-up of 92 675 operations performed 19781990. Acta Orthop Scand 1993;64:497-506. 22. Britton AR, Murray DW, Bulstrode CJ, McPherson K, Denham RA. Long term comparison of the Charnley and Stanmore design total hip replacements. J Bone Joint Surg [Br] 1996;78-B:802-8. 23. Garellick G, Malchau H, Herberts P. Charnley versus Spectron: a randomised prospective study on cemented hip arthroplasty using contemporary technique. Acta Orthop Scand 1994;65(Suppl 260): 68-9. 24. Havelin LI, Espehaug B, Vollset SE, Engesaeter LB. Early failures among 14 009 cemented and 1326 uncemented prostheses for primary coxarthrosis: the Norwegian arthroplasty register, 1987-1992. Acta Orthop Scand 1994;65:1-6.